Scalp Vein Catheterization 

Updated: Dec 17, 2020
Author: Ethan Bergvall, MD; Chief Editor: Vincent Lopez Rowe, MD 

Overview

Background

Vascular access is an important, sometimes critical, step in the care of sick infants and children. Peripheral vascular catheterization provides a direct route for administration of fluids and medications. Many anatomic sites are available for intravenous (IV) catheterization, with peripheral sites being the most common and most readily available. For more information, see Vascular Access in Children.

Placing an IV line into a peripheral vein in a small child or infant can be a difficult task, for many reasons. Small children and infants have smaller peripheral veins, they may have more subcutaneous fat, they are prone to vasoconstriction, and they are much less likely to remain motionless and cooperative during a painful procedure than adults. The scalp veins provide a secondary option for peripheral intravascular access in small children and infants by virtue of the minimal subcutaneous fat, the reduced movement, and the lack of a flexible joint; these factors reduce the likelihood of catheter dislodgment, which is common with IV catheters placed in the arms or legs.

Indications and Contraindications

Scalp vein catheterization is indicated in any patient who requires intravascular access for the administration of fluids or medications.

The decision to attempt access via one of the scalp veins should be based on inspection or palpation of various sites. Although the scalp veins provide certain advantages, the best site at which to attempt access is whichever vein the clinician feels offers the greatest chance for successful catheterization on the basis of his or her ability to visualize or palpate the vessel. Using scalp veins can also help preserve the vessels of the arms and legs for peripherally inserted central catheters (PICCs).[1]

Scalp vein catheterization is often considered only after attempts to insert a catheter at other peripheral sites have failed.

Attempting IV access near sites of superficial skin injury or infection should be avoided.[2]

 

Periprocedural Care

Equipment

Having the appropriate equipment is of utmost importance for successful scalp vein catheterization. Minimum equipment required includes the following:

  • Elastic band tourniquet
  • Adequate lighting
  • Antiseptic wipes
  • Syringes, filled with 0.9% saline, for flush
  • Tape for securing the intravenous (IV) catheter and tubing
  • Appropriately sized IV over-the-needle catheter - Catheters of 22-24 gauge are frequently selected for use in small children and infants and are usually an appropriate choice for the scalp veins

Patient Preparation

Anesthesia

Use of anesthesia is generally not indicated. Topical anesthesia may be considered with the use of a lidocaine cream or patch, but these require at least 20-30 minutes to be effective. For more information, see Anesthesia, Topical.

Positioning

The patient should be lying in a supine position with his or her head turned so that the desired scalp vein is visible and readily accessible. The clinician should be located at the head of the bed with the patient’s feet extending away from the clinician. A slight head-down position may facilitate catheterization by distending the veins of the head and neck. To minimize the risk of injury to either the patient or the clinician, care should be taken to ensure that the patient is appropriately restrained.

 

Technique

Catheterization of Scalp Veins

Locate the frontal, superficial temporal, or posterior auricular vein in the scalp (see the image below). To minimize the risk of leaving a visible scar, select a site that is behind the hairline. Shaving the site may be necessary to allow proper visualization and to properly secure the catheter once it has been inserted.

Common sites of insertion for peripheral scalp vei Common sites of insertion for peripheral scalp vein catheterization include frontal, posterior auricular, and superficial temporal veins.

Place an elastic band around the patient’s head just above the eyes and ears from forehead to occiput, or occlude the vein proximally with the index finger of the nondominant hand (see the image below).

Elastic band is used as tourniquet to distend scal Elastic band is used as tourniquet to distend scalp veins. Small piece of tape attached to elastic facilitates removal.

Clean the site of insertion thoroughly with antiseptic wipes. Use the thumb of the nondominant hand to secure the vein distally to the insertion site to prevent movement of the vessel.

Hold the intravenous (IV) needle and catheter in the dominant hand, parallel to the vessel, pointing in the direction of blood flow. Insert the needle into the vein, angled 20-30º off the skin surface (see the image below). When the needle enters the vessel lumen, a flash of blood should be seen in the hub of the catheter.

Catheter-over-needle device is inserted at 30-degr Catheter-over-needle device is inserted at 30-degree angle to skin surface, with needle pointing in direction of blood flow; flash of blood is seen in hub as needle enters lumen of vein.

Carefully lower the needle and catheter until they are just off the skin surface, and advance slightly further into the vein so that both the needle and the catheter tip are in the vessel lumen (see the image below).

Once needle has entered vein, catheter-over-needle Once needle has entered vein, catheter-over-needle device is (1) lowered so that it is just off skin surface, then (2) advanced slightly further to ensure that both needle tip and catheter tip are in vessel lumen.

Slide the catheter forward off the needle using the nondominant hand while continuing to hold the needle in place with the dominant hand (see the image below).

When both needle tip and catheter tip are inside v When both needle tip and catheter tip are inside vessel lumen, catheter is advanced forward (1) off needle and further into vein.

Once the catheter has been advanced completely into the vein, secure the catheter with the index finger of the dominant hand by compressing the skin overlying the vein where the tip of the catheter lies. Use the middle finger of the same hand to compress the vein immediately proximal to the catheter tip to prevent bleeding from the IV line while the needle is removed.

Attach extension tubing preflushed with saline and a saline-filled syringe (see the image below). Gently inject saline solution into the catheter, and observe for any infiltration into surrounding tissues.

IV extension tubing (preflushed with normal saline IV extension tubing (preflushed with normal saline) is attached to catheter after removal of needle. Saline-filled syringe is used to gently flush catheter while observing for signs of infiltration.

If no infiltration is seen, secure the catheter in place with a clear, sterile adhesive dressing (see the image below). This prevents manipulation and contamination of the entry site and allows visualization for frequent assessment. Place rolled 2 × 2 cm gauze under the catheter hub to prevent pressure on the underlying skin.

Catheter is secured with clear plastic dressing. F Catheter is secured with clear plastic dressing. Folded piece of 2 × 2 cm gauze is used to protect skin from hard plastic of catheter hub and extension tubing connector.

Secure the extension tubing onto the skin with tape (see the image below).

Extension tubing is secured with tape to prevent i Extension tubing is secured with tape to prevent inadvertent removal of catheter.

Pearls

Shaving the site prior to catheterization makes taping the catheter in place easier and more secure.

Carefully warming the site before attempting catheterization can improve vasodilatation and make catheterization easier. Caution is necessary to prevent burns.

Attaching a piece of tape to the elastic band tourniquet (see the image below) facilitates removal while decreasing the chances of inadvertent disruption of the vein or the catheter.

Elastic band is used as tourniquet to distend scal Elastic band is used as tourniquet to distend scalp veins. Small piece of tape attached to elastic facilitates removal.

Keep in mind that tourniquets are more likely to disrupt the scalp veins than vessels at other peripheral sites.

Attempting to advance the catheter over the needle before the catheter tip is in the vessel lumen can push the vein off the needle and prevent successful catheterization.

Complications

Hematoma is reported as the most common complication from peripheral IV catheterization; fortunately, it is often insignificant.[2, 3] Vasospasm is also a common complication and usually is significant only insofar as it makes successful catheterization difficult.[2]

Less common but more significant complications include the following:

  • Phlebitis [2, 4, 5, 6]
  • Infection [2, 4]
  • Embolization of air or clots (possibly to cerebral veins) [7, 8]
  • Injury of adjacent structures (artery or nerve)
  • Infiltration of subcutaneous tissues with IV medication or fluids, which may result in superficial blistering, deep tissue necrosis, or tissue calcification if calcium-containing fluids are used [2, 4]

Accidental intracranial infusion of parenteral nutrition in a preterm neonate has been reported.[9]

A retrospective review by Callejas et al compared complication rates for peripherally inserted central catheters (PICCs) in neonates via scalp (69 insertions), upper-limb (471), and lower-limb veins (149).[10] The complication rate for insertion via scalp veins was 23%, compared with 23% for upper-limb veins and 15% for lower-limb veins. Central line–associated bloodstream infection occurred at a rate of 4.4 per 1000 catheter days with scalp-vein insertion, compared with 6.4 per 1000 with upper-limb insertion and 3.4 per 1000 with lower-limb insertion.

With PICC use, migration of the catheter tip may lead to complications. For PICCs inserted via the scalp, serial follow-up x-rays, beginning 1 week after insertion, may be helpful in detecting catheter-tip migration and identifying patients at risk.[11]